a journey through heartache

8/20/2019 A Journey Through Heartache

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A JOURNEY THROUGH

HEARTACHE

EXTERNAL REVIEW RESPECTING THE GOVERNMENT OF NUNAVUT’S ACTIONS

REGARDING THE DEATH OF BABY MAKIBI, CAPE DORSET, 2012

Katherine Peterson NOVEMBER 2015


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A JOURNEY THROUGH HEARTACHE

FINAL REPORT

TABLE OF CONTENTS

Page

Executive Summary

Part I Introduction 1

Part II Community Health Care 3

Part III Background Information 6

1.

Initial Circumstances 62. Government Personnel and Response 7

Part IV Issues Posed in the Terms of Reference

1. Does the Department of Health have

a specific process for completing an

internal review into the administrative

processes of a case 14

2.

If so, were they followed in this case

(a) Critical Incident Reporting 16

(b) Monitoring and Evaluation 23

3. What were the findings of the internal


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Review completed by the Department

of Health 25

4. Were all Government of Nunavut policies,

Procedures, training and guidelinesrespecting nursing care, standards of

nursing care and complaints processes

followed in the Timilak case 31

(a) Nursing Care and Standards of

Nursing Care 31

(b) Complaints 32

(i) Complaints to RNANTNU 33

(ii)

Complaints to the Officeof Patient Relations 34

(iii)

Complaints General 35

5. Were the existing Human Resource policies,

Procedures, training and guidelines respecting

Employee Relations and Performance

Management followed and adequate 37

6. What interaction and mechanisms exist

Between the Department of Health, the

Department of Finance (Employee Relations),

the Department of Justice, the Chief Coroner,

and the Registered Nurses Association of

Northwest Territories and Nunavut regarding

Complaints relating to registered nurses 40

(a) Department of Health and RNANTNU 40

(b)

Department of Health and the Office

of the Chief Coroner 41

(c) Department of Health and the

Department of Finance (Employee

Relations) 42

(d) Department of Health and the


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Department of Justice 44

7. How can the Government of Nunavut improve

Its procedures in order to provide for a more

responsive system for receiving and addressingcomplaints related to nursing care in

Nunavut 45

(a) Complaints Processes 45

(b) Health Employee Management 46

(c) Role of the Office of Patient Relations 48

(d) Chief Nursing Officer 48

8. How can the Government of Nunavut increase

Transparency in its communications with the

Public and affected parties following incidents,

while respecting its obligations under the Access

to Information and Protection of Privacy Act 50

Part V General Concluding Commentary 52

Tab 1 Terms of Reference

Tab 2 List of Persons Interviewed

Tab 3 Timeline of Events

Part VI Recommendations 61


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EXTERNAL REVIEW RESPECTING THE GOVERNMENT OF NUNAVUT’S

ACTIONS FOLLOWING THE DEATH OF BABY MAKIBI, CAPE DORSET,

NUNAVUT

“A JOURNEY THROUGH HEARTACHE”

EXECUTIVE SUMMARY

1. Background Facts

The Cape Dorset Health Centre was contacted by telephone by a parent of Baby

Makibi at approximately 9:00 pm on the evening of April 4, 2012. Nurse

McKeown took the phone call. Concern was expressed that Baby Makibi was notsettling. Nurse McKeown advised that the baby be bathed and brought into the

health Centre the following day. There are factual conflicts as to the extent

inquiries were made as to the condition of Baby Makibi at the time of this phone

call. Several hours later Baby Makibi was rushed to the Health Centre,

unresponsive, and could not be revived.

The death was initially reported in April 2012 by the Chief Coroner as a SIDS

death. The cause of death was amended by the Coroner in July 2012 to death asa result of widespread pulmonary infection. In October 2015 the cause of death

was again revised to SIDS.

All critical incidents are to be reported immediately pursuant to the guidelines set

out in the Community Health Administration Manual. Steps following the report

of a critical incident include investigation, review, assessment, root cause analysis

and development of remedial steps.

Prior to this fatality occurring, complaints had been made in writing by nurses to

the Department of Health regarding the operation of the Cape Dorset Health

Centre. Grievances were filed with the GN regarding the operation of the health

centre and treatment of staff prior to the fatality. In addition, a complaint had


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been filed by a nurse with RNANTNU regarding both the operation of the health

centre and clinical concerns.

RNANTNU is not able, for privacy reasons, to communicate with any parties other

than the complainant and the party complained about when acting on acomplaint. RNANTNU placed conditions on the license of Nurse McKeown in June

2012 prohibiting her from providing care to children under the age of 10 years.

2. Responses by the Department of Health to the fatality

An investigation regarding a harassment complaint submitted by Gwen Slade

(which complaint was submitted in January 2012) was undertaken by the

Department of Health resulting in a preliminary finding that, prima facie,harassment had occurred and a full investigation should be undertaken. It is

entirely unclear whether this investigation occurred. A written reprimand

directed to Ms. McKeown was prepared and signed on behalf of the Department

by the then Deputy Minister. Again, it is entirely unclear whether this reprimand

was actually delivered to Ms. McKeown.

The fatality was not duly reported/investigated as a critical incident pursuant to

the Community Health Administration Manual. Consequently, no investigation or

assessment was undertaken immediately following the incident.

When conditions were placed on Ms. McKeon’s license in June 2012 no details of

the license restriction were recorded at Regional Office, nor, it appears, were

there any steps taken to ensure adherence to the restrictions.

No investigation specific to the Timilak death was undertaken by the Department

of Health at the time of the fatality, at the time of imposition of license

restrictions on Ms. McKeown or at any time after the fatality. An investigation

was undertaken by Regional Office in the summer of 2013, which was focussed on

further harassment complaints that had been submitted by (then) recent

employees of the Cape Dorset Health Centre. Accordingly, there has been no

systematic review or investigation by the Department of Health into the

circumstances surrounding the death of Baby Makibi.


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The failure to conduct a timely and appropriate investigation regarding the death

of Baby Makibi likely arises as a result of:

•

The failure by responsible bureaucrats to properly report/investigate thedeath in accordance with the Community Health Administration Guidelines;

• The failure of communication between the District Supervisor, South Baffin

and Regional Office;

• The failure to respond to known difficulties existing in the operation of the

Cape Dorset Health Centre, which facts were known by Regional Office and

District Supervisor, South Baffin in 2012 prior to the death of Baby Makibi.

The response of Regional Office and the Department of Health generally to thedeath of Baby Makibi appeared to be due more to external pressure than internal

controls and steps.

The undertaking of regular performance appraisals, and record keeping regarding

complaints and disciplinary steps respecting nurse employees is almost entirely

absent, and when present, is disorganized and disjointed. As a result, limited

avenues were available to Employee Relations regarding the ongoing employment

of nurse Debbie McKeown.

Key Conclusions in the External Review

1.

Two policies in the Community Health Administration Manual mandate an

in person assessment of infants under the age of one (1) year. These

policies were not followed by Nurse McKeown at the time the mother of

Baby Makibi contacted the Health Centre on April, 4, 2012. This Report is

not mandated to conclude, nor does the author have the expertise to

conclude whether this would or would not have resulted in the survival of

Baby Makibi.

2. There is a specified process for the reporting and investigation of critical

incidents. A report was made by the attending nurse, D. McKeown to the

District Supervisor, South Baffin (Heather Hackney) who in turn prepared a


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Briefing Note regarding the incident which states it was copied to Regional

Office. However, follow up investigations, root cause analysis, meetings

with the family, collection of documents and witness statements did not

occur.

3.

There is a specified process for monitoring and evaluating the ongoing

operation of a Health Centre, including annual visits, performance

appraisals, assessment of connection with the community. This process

either did not occur, or if it did occur, was sporadic and undocumented.

4.

District and Regional offices have no specified process for the investigation

and resolution of complaints regarding access to or competency of nursing

care.

5.

The investigation that was undertaken by Regional Office in Cape Dorset

occurred in the late summer of 2013 and was in response to a further

harassment complaint regarding D. McKeown. It was not in response to

the death of Baby Makibi and that fatality received only a peripheral

mention at the time this investigation occurred.

6.

There was no investigation undertaken by the Department of Health

specific to the death of Baby Makibi at the time of the fatality nor at any

time thereafter. This was despite the fact that difficulties regarding the

Cape Dorset Health Centre were known to Regional Office, the death was

reported to Regional Office, Regional Office was aware of license

restrictions (not to engage in pediatric care) on the license of D. McKeown.

The only investigation specific to the death of Baby Makibi was a chart

review conducted in the fall of 2012.

7.

D. McKeown was promoted to Supervisor at the Cape Dorset Health Centre

despite known restrictions on her license at the time of promotion and

awareness of prior concerns having been raised regarding her conduct in

the workplace.


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8.

There is an absence of documentation regarding employee appraisal,

discipline, and fact finding investigations. There is an absence of

communication and documentation regarding these matters as between

Regional Office and Human Resources and Employee Relations. The failure

to properly document resulted in reduced options regarding the ongoingemployment of D. McKeown.

9.

There are silos of information and action as between various arms of Health

Care including communication with and between the Department of Health

and RNANTNU, Human Resources, Employee Relations, the Office of the

Chief Coroner, resulting in disjointed and poorly managed responses to

critical situations.

10.

The varying reports of the Chief Coroner as to the cause of death of Baby

Makibi has left the community of Cape Dorset uncertain as to the facts,

medical opinions, distrustful and angry. Various versions of events at the

time have emerged leaving a situation of conflicting facts. These conflicting

facts and medical opinions are best addressed by a formal Inquest in the

community regarding the death of Baby Makibi.

11.

The community of Cape Dorset continues to have a troubled relationship

with the Health Centre. This is evidences by a lack of trust, anger and, at

times, inappropriate conduct by patients at the Health Centre. Some, but

not all, of this troubled relationship arises as a result of the death of Baby

Makibi. Other factors contributing to it likely also include historical trauma,

dysfunctional family dynamics, substance abuse, to name a few.

12. Both the actions and omissions of the Regional Office regarding issues

respecting the Health Centre in Cape Dorset signify a lack of knowledge and

engagement by that Office regarding issues of extreme significance to

community members in Cape Dorset. These actions and omissions include a

failure to investigate Baby Makibi’s death as mandated in the Community

Health Administration Manual.


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Key Recommendations

1.

Structural changes should be made in the Department of Health:

• All HC employees report through the same chain of command;

•

Position of Chief Nursing Officer be entrenched and appropriately

resourced for an expanded mandate;

• Department of Health assume responsibility for discipline and

termination of HC employees;

• A two pronged reporting regime regarding critical incidents be

instituted;

•

Defined policies for communication with affected Departments,

for handling complaints and reporting outcomes be developed.

2.

A complaints procedure be defined and instituted at Health Centres;

3. An Inquest be held into the death of Baby Makibi;

4.

Personnel requirements at Health Centres and Regional Office be

reassessed to alleviate overwhelming workloads, and match skills to

community needs;

5. Nursing staff should receive timely and culturally appropriate

orientation, respite time, peer to peer mentoring, and provide consents

for release of information from RNANTNU regarding past history andcurrent complaints/investigations and outcomes;

6.

The External Review Report, and the GN response to same be publicly

released, with Department officials being available to meet with

community members to explain and discuss the Report and

Recommendations.


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EXTERNAL REVIEW RESPECTING THE GOVERNMENT

OF NUNAVUT S ACTIONS FOLLWING THE DEATH OF

BABY MAKIBI, CAPE DORSET, NUNAVUT

A JOURNEY THROUGH HEARTACHE”

Part I INTRODUCTION

On April 5, 2012 Baby Makibi Timilak died in Cape Dorset, NU at the age ofthree months. The death was initially reported by the Chief Coroner,

Nunavut as a “SIDS” death – Sudden Infant Death Syndrome in an

otherwise healthy child.1 It was thereafter reported as a death due towidespread pulmonary infection.2 Most recently (October 2015) it wasagain reported as a SIDS death.3 These (and other) circumstances gaverise to the request by the then Minister of Health, Monica Ell, for anExternal Review.

The Terms of Reference for this External Review, commissioned onFebruary 23, 2015, are attached as Appendix 1 to this Report. While theTerms of Reference refer specifically to the events following the death ofBaby Makibi, circumstances which occurred prior to his death form animportant context in this matter and therefore cannot be excluded from theanalysis in this Review. In addition, the contrasting reports from the Officeof the Chief Coroner as to the cause of death are of considerable concern.

In conducting the Review, I interviewed persons who offered informationregarding the events leading up to and occurring after this tragic fatality.

The list of persons interviewed is attached to this Report as Appendix 2.Many of the interviews were conducted in person, and where interviews

1 Report of Coroner April 11, 2012;2 Report of Coroner July 24, 2012, Supplementary Report of Coroner; Registration of Death September 13, 20123 Opinion of Dr. S. Phillips, Department of Pathology, Health Sciences Centre, Winnipeg, MN July 27. 2015,

Coroners Report October 20, 2015


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were conducted by telephone, this is indicated in the Appendix. Oneperson, namely Debbie McKeown, attending nurse at the Cape DorsetHealth Centre at the time of this fatality, declined to be interviewed orparticipate in this Review. Reasons cited were the existence of litigationinitiated by Ms. McKeown respecting professional disciplinary proceedings.

Volumes of documents were also reviewed in the preparation of thisReport. These documents included those which were produced by Accessto Information and Protection of Privacy (ATIPP) requests of variousindividuals, as well as source documents such as the Department of HealthPolicies and Procedures Manuals, Department of Health file materials,legislation, and other relevant materials. Without exception, Department ofHealth officials provided documents and information as requested and in atimely fashion.

The purpose of this Report is not to find fault with any individual or group ofindividuals, but rather to examine those circumstances and processeswhich existed which may have had an impact and to providerecommendations which could prevent such a tragedy from occurringagain.

Many individuals gave freely of their time, offered advice and perspectives,which I hope have been appropriately analyzed and depicted in this Report.The Report could not have been prepared without this input, and I wish tothank those who contributed. Many did so despite painful personalcircumstances, or difficult professional situations. I would particularly like tothank Neevee Akesuk and Luutaaq Qaumaqiaq, the parents of BabyMakibi, who agreed to meet with me in Cape Dorset in the presence of theirlegal counsel. Their comments and perspectives were extremely valuablein undertaking this matter.


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PART II COMMUNITY HEALTH CARE

Health care in Nunavut is administered by the Department of Health, with

involvement of the Department of Finance regarding Employee Relationsmatters. At the community level, health care is accessed throughCommunity Health Centres, which vary in size depending on the populationserved. Community Health Centres provide ongoing care, emergencycare, and community health programs such as immunizations. The staff ofa Community Health Centre typically includes administrative staff, technicalstaff (for the operation of equipment such as imaging equipment), staffresponsible for homecare, mental health, and nursing staff. The nursingstaff is comprised of a Supervisor, Health Programs (sometimes known asthe Nurse in Charge), and community health nurses. The Nurse in Charge

of a Community Health Centre reports to the Director of Health Programsfor the region, who in turn reports to the Regional Director of Health for theregion.

Community Health Nurse (CHN)

Supervisor Health Centre or Nurse in Charge (SHP)

Director of Health Programs, South Baffin

Regional Director of Health

Generally speaking, nursing care is provided by three categories of nurses:Indeterminate staff (full time permanent Government of Nunavut staff),Casual staff (GN employee) and Agency nurses. Agency nurses are thoseindividuals hired from southern agencies for short term contractual periods.


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Many agency nurses have practiced in various communities in Nunavutand the Northwest Territories over long periods of time.

There are contrasting schemes of remuneration as between the variouscategories of nurses. For example, agency nurses will be provided withtransportation between their home community (usually in southern Canada)and their place of work, as well as accommodation in the community inwhich they provide nursing services. However, benefits such as pensionsare not provided in their contracted services. Current GN practices make itmore advantageous to nurses who do short term assignments in thecommunities rather than becoming a full time employee and a permanentmember of the community. Some of these advantages include short termcontracts with breaks in between, flights in and out of the community,subsidized rental accommodations, and cargo allowances. As a result, it is

difficult for the Department of Health to attract and retain long termpermanent nurses.

All nurses practicing in Nunavut (and in any other jurisdiction in Canada)are governed by the applicable Registered Nurses Association. In thiscase, nurses in Nunavut are governed by the Registered Nurses

Association NT/NU (RNANTNU). A practicing nurse must be licensed bythis organization and his or her professional practice is reviewable by it.Complaints made to RNANTNU regarding clinical or ethical practice areinvestigated by this organization and can result in discipline of the membernurse, including suspension of the license to practice.

Generally speaking, Nunavut is plagued by a chronic shortage of qualifiednurses. Recruitment and retention of nursing staff is the single mostchallenging issue in the delivery of community health care. A largeproportion, as high as 40% at times, of nursing care is provided by Agencynurses. Barriers exist for those trained in nursing in Nunavut, including theclinical placement of nurses. The low proportion of Nunavut trained andInuit nurses also arises from low enrollment and /or low graduation from the

Arctic College nursing program and the difficulties associated withengaging in a long term and demanding program in Iqaluit.

As with other community Health Centres, the Cape Dorset nursing staff hasan extensive and broad scope of practice. There is no resident physician inthe community, and assistance and advice is received by telephone,


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electronic communications, and periodic visits by physicians. As such,nurses practicing in this environment are not only tasked with assisting inthe general well being of the community population, but may also have torespond to extreme emergency situations. They are providing services to alargely Inuit population, with a distinctive culture and distinctive and varyingcommunication skills. It is a stressful and demanding work environmentwhich requires an extremely diverse range of skills. In addition, the nursingstaff are working, and at times living together, in close quarters and isolatedconditions. The combination of the scope of work and the workingconditions require not only specific professional skills, but a personaldynamic that is both compassionate and professional. Workloads at theCommunity Health Centre can be overwhelming and contribute to burn outof professional and administrative staff.

The members of the community seeking health care at the Health Centreare also faced with language and cultural divides which can at times createobstacles to understanding and care. Trust in the competency andcompassion of community nurses is an integral part of this relationship.For some members of the Community of Cape Dorset, this trust has beendamaged or lost. Community members have at times felt unwelcome anddisrespected. Similarly, trust and compassion on the part of practicingnurses in the community has at points been damaged or lost as a result ofdifficult, demanding or disrespectful conduct on the part of patients. Thecommunity of Cape Dorset continues to have an uneasy relationship withmembers working in the Health Centre. This contributes to high turnover inHealth Centre staff, anger and frustration on the part of communitymembers and Health Centre staff.


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PART III BACKGROUND INFORMATION

1. Initial Circumstances

Baby Makibi was the first child of his young parents who resided in theCommunity of Cape Dorset, Nunavut. Cape Dorset is served by a busyHealth Centre, with a complement of five nursing staff plus relatedadministrative staff.

The mother of Baby Makibi contacted the Health Centre by telephone onthe evening of April 4, 2012 at approximately 9:00 p.m.. The call was takenby the on duty nurse, Debbie McKeown. The details of this conversation

are in conflict. It is clear that the mother contacted the Health Centrebecause she was concerned about her infant, and particularly that he wasnot settling. She was advised to bathe the infant and to come in for acheck up the following day.4 The infant was not seen by the on duty nursedespite clear Department of Health policies. The policies state:

Policy 07-006-00 Telephone Triage

“Every client shall be assessed on an individual basis. The following

individuals shall have their presenting complaint fully assessed in the

clinic:

…

2. All infants up to one (1) year of age.”5

Policy 07-008-00 Acutely Ill Infants

“ All infants under one (1) year of age must be fully assessed in the

clinic, whether it is during or after regularly scheduled clinic hours.”6

The mother Neevee breast fed Makibi and he relaxed and was smilingthrough the night until they went to sleep.7 Baby slept with his parents, on

4 Statement of Luutaaq Qaumagiaq to RCMP officer Lawson5 Community Health Administration Manual, Telephone Triage, Policy 07-006-006 Community Health Administration Manual, Nursing Practice, Policy 07-008-00


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his stomach as this was the only position in which he would sleep well.8 Nurse McKeown was advised that Makibi went to sleep around 2230/2300hrs910

Several hours later, Baby Makibi was rushed to the Health Centre,unresponsive, and could not be revived.

The initial Coroner's report on April 10, 2012 regarding this fatalitydescribed it as a "SID"s death. However, in the Report of the Coroner

dated July 24, 2012 it is stated that the cause of death was “widespread

Pulmonary Cytomegalovirus Infection, Bilateral, SUDI”11 The

Supplementary Report states that microscopy sections from all lobes ofboth lungs showed moderate to marked congestion and that there was

evidence of cytomegalovirus infection.12

The last opinion of the Coroner arising from a medical opinion dated July27,2015 again reverts to the cause of death being SIDS.13

2. Government Personnel and Response

Key players at the time of this tragedy and in the months following included:

Deputy Minister Health Peter MaRegional / Executive Director, Baffin Roy InglangasukDirector of Population Health, Baffin Markus WilkeDirector of Health Services (ending October 2012) Virginia TurnerDirector of Health Services, South Baffin(ending March 2013) Heather Hackney

7 Statement of Luutaaq Qaumagiaq to RCMP officer Lawson8 Statement of Luutaaq Qaumagiaq to RCMP officer Lawson9 Statement of Debbie McKeown to RCMP officer Lawson10 There are a number of conflicts in these facts as between the parents and Nurse McKeown, such as what were

reported as symptoms, whether Baby slept in a crib.11 Report of Coroner dated July 24, 2012.12 Supplementary Report Additional Information of the Deceased13 Opinion of Dr. S. Phillips ,Coroners Report October 20, 2015 supra


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Director of Health Services (April 2014) Elise Van SchaikDirector of Professional Practice Barbara HarveySupervisor Health Programs (Cape Dorset) Susan ValidenSupervisor Health Programs (Cape Dorset) Lennie SapachCommunity Health Nurse Cape Dorset Debbie McKeownCommunity Health Nurse Cape Dorset Karen RaeCommunity Health Nurse Cape Dorset Gwen SladeChief Coroner Padma SuramalaClinical Supervisor Mary Bender

Acting positions were assumed by a number of these individuals at variouspoints. It was not uncommon for Regional Office personnel to assumemultiple responsibilities at any given point in time and for District personnelto do the same respecting regional positions. Turn over in key positions,

such as the Director of Health Services, has impacted both service deliveryand processes to a very large degree.

At the time of Baby Makibi's death, Lennie Sapach occupied the position of

Supervisor Health Centre (“Nurse in Charge”), Debbie McKeown was part

of the nursing staff , and Gwen Slade had been previously employed inCape Dorset as a casual nurse. Heather Hackney occupied the position ofDirector of Health Services, South Baffin. Regional Office staff was comprised of Roy Inglangasuk, Virginia Turner, and Markus Wilke. 14

Earlier in the fall of 2011 Karen Rae, employed as a nurse at Cape Dorset,expressed concerns respecting the work environment in place at the CapeDorset Health Centre. At the request of Heather Hackney, Director ofHealth Services, South Baffin, these concerns were provided in writing.These concerns were detailed in a nine page email, and includedallegations of:

- bullying and harassment by the then Health Centre Supervisor,

Susan Validen;- poor judgment, lack of support and lack of managerial skills on thepart of Susan Validen;

14 This is not a full list of Regional Office staff, nor Health Centre staff, but only those mostdirectly involved with events.


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- Bizarre behaviour and lack of clinical skills on the part of SusanValiden;

- security and safety issues regarding nursing staff;- the bringing of a premature infant receiving care at the Health Centre

to a social party by one of the nursing staff;- inappropriate guests at the Health Centre, drinking, and socializing on

the part of Health Centre staff;- favouritism r especting certain employees, particularly Debbie

McKeown.15

This lengthy email contains a litany of disturbing allegations, many ofwhich, if substantiated, would impact not only the functioning of the HealthCentre, but the quality and competency of care provided to patients.

As a result of this email, a fact finding investigation was conducted byHeather Hackney, and Susan Validen was removed from the position of

Supervisor or “Nurse in Charge” at the Centre, replaced by Lennie Sapach.

However, Susan Validen remained part of the nursing staff at the HealthCentre for some months thereafter.

While it is clear that these actions provided some immediate relief fromwhat appeared to be a dysfunctional work environment, serious issuesremained, and sadly, were to resurface within months. The continued

allegations included bullying behaviour on the part of some nursing staff,including Debbie McKeown, credibility, work ethic and competencyconcerns, responsiveness to nursing staff concerns, and general quality ofcare.

In January and February 2012, concerns were again raised regardingconduct and functionality of the Cape Dorset Health Centre. It is likely thatconcerns were also communicated prior to this time, althoughdocumentation in this regard was not available. The unavailability could be

as a result of concerns being raised orally, or due to documentation notbeing maintained. However, it is clear that concerns were communicatedby Gwen Slade, who had returned to the Health Centre in January 2012. Atotal of four grievances (originally framed as complaints) were submitted by

15 Email Karen Rae to Heather Hackney dated September 16, 2011


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Gwen Slade, in addition to complaints filed with RNANTNU regardingLennie Sapach and Debbie McKeown. These actions resulted in Ms. Sladebeing suspended pending investigation and leaving the community of CapeDorset in February 2012. Apart from Ms. Slade no other suspensionspending investigation occurred.

It appears that the bureaucratic response to the concerns raised with theGN by Ms. Slade was defensive in nature. The focus at the time was thatof refuting allegations made by Ms. Slade rather than the investigation ordetermination of the validity of these complaints. The credibility of Ms.Slade was treated as suspect from the outset. It is critical to note that nofurther investigations were conducted regarding the functionality of theCape Dorset Health Centre nor the quality of care being offer by it, until thesummer of 2013, in excess of one year after the death of Baby Makibi.

Incredibly, the grievance process initiated by Ms. Slade has only recentlybeen completed in October 2015.

As mentioned above, in February 2012 Ms. Slade filed a complaint withRNANTNU respecting Lennie Sapach and Debbie McKeown.

As a result of these complaints and investigations by RNANTNU, it learnedof concerns regarding the circumstances of the death of Baby Makibi.

The complaint to RNANTNU regarding Ms. McKeown initially resulted inrestrictions being placed on her practice in June 2012, namely:

"The member will not provide nursing or other health care services toany patient who is younger than 10 years of age other than emergencysituations".

This determination was achieved as a result of an Alternate DisputeResolution process in which Ms. McKeown voluntarily participated. It

included remedial steps to be taken by Ms. McKeown.

In March 2012 a complaint to RNANTNU was filed by Heather Hackneynaming Gwen Slade. This complaint was investigated and ultimatelydismissed. Given the timing of this complaint, and the circumstancespreceding it, the complaint has a distinctly retaliatory or punitive flavour.


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The death of Baby Makibi was not fully reported/ investigated as a criticalor serious incident. A report of some description was provided by DebbieMcKeown to Heather Hackney. Details of what was contained in this reportwere not discoverable by me apart from an email dated April 5, 2012reporting the fact that a 3 month old infant had died. However, HeatherHackney advises that she contacted Debbie McKeown to ascertain details.

Again, documents in this regard are either missing or were never prepared. A Briefing Note was prepared by Heather Hackney April 5, 2012, the very

day of Baby Makibi’s death. The Briefing Note bears the notation of a copy

to Roy Inglangasuk, Regional Director. It appears that an assessment was

made that because the infant was not “acutely ill” the protocol for in person

assessments of all children under the age of 1 year did not apply.

Ms. Hackney advised that she “apprised and sent documentation to my

supervisor (Roy Inglangasuk) of the situation concerning baby Macabie’s

(sic) death, interim settlement agreement and the decision to accommodate

Debbie [McKeown] in the Acting Supervisor position”. Regional Office (Roy

Inglangasuk) advised that these documents were not provided. Whenasked whether, when he learned of the restrictions placed on Ms.

McKeown’s license in June 2012 he investigated or “dug into” the matter,

his response was “not really”. He stated that he was advised “at a

superficial level” of the incident, and that “now” Ms. McKeown had to have

restrictions on her license.

However, it is clear from the documents reviewed that Mr. Inglangasuk wassubstantially aware of the issues in Cape Dorset in early 2012. InFebruary 2012 Mr. Inglangasuk advised in an email directed to Heather

Hackney and Virginia Turner that he would be “taking the lead on this

file”.16

16 Email dated February 19, 2012 from Roy Inglangasuk to Heather Hackney, cc to Virginia Turner in reference to

the harassment complaint of Gwen Slade and presumably matters generally arising in Cape Dorset


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Although Mr. Inglangasuk “took the lead”, there appears to have been:

• no substantive or pro active steps regarding complaints,

• no investigation into the death of Baby Makibi and the reasons forthe license restrictions,

• no request to Ms. McKeown regarding the details of the licenserestrictions so that they could be recorded on file,

• No arrangement for the monitoring of adherence to the licenserestrictions imposed on Ms. McKeown and,

• after the fact, a disavowal of any detailed knowledge, indicating that

his Directors had “let him down” by withholding information” from

him.

As indicated above, it appears that the Briefing Note prepared April 5, 2012regarding the death of Baby Makibi was copied to Mr. Inglangasuk.

In May 2013 Mr. Inglangasuk corresponded with RNANTNU stating:

“We will be interviewing for the Nurse Manager position for our Cape

Dorset Health Centre, however, Debbie advises that she is still waitingfor your organization to determine if she has met the remedialrequirements placed on her license. I agree with Debbie this is going

at a snail’s pace and not conducive to our staffing process. With the

caveats placed on her license it may be impossible to interview her forthe position.Debbie has proven to be a good manager for our health centre andenjoys the support of her staff and from my office because we have a

well managed and operated health centre in a busy environment.”17

This endorsement of Ms. McKeown was made at a time when Mr.Inglangasuk was aware of the harassment complaints, the death of Baby

Makibi, and the restrictions on Ms. McKeown’s license.

17 Email dated May 7, 2013 from Roy Inglangasuk to RNANTNU, Subject Debbie McKeown, Acting Nurse

Manager Cape Dorset


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He was advised May 7, 2013 by RNANTNU that restrictions remained onthe license of Ms. McKeown.

In an email directed to RNANTNU on January 7,2014, details of the licenserestriction were requested by Mr. Inglangasuk. This further indicates thatparticulars of those restrictions, although known to be in place, were neverpreviously sought or recorded.

Despite Mr. Inglangasuk’s concerns communicated to RNANTNU that Ms.

McKeown may not be interviewed for the Nurse in Charge position forCape Dorset because of the restrictions on her license, this in fact occurredor at least, whether or not the interview occurred, Ms. McKeown waspromoted to the full time permanent position of Supervisor or Nurse inCharge of the Cape Dorset Health Centre in June 2013. The licenserestrictions continued to be in place at this time. Ms. McKeown hadpreviously been acting in this position.

The work of the Health Centre had a very high proportion of pediatric andobstetrical care. Such care occupies the majority of services provided bythe Health Centre. There is also a well known custom of clinic nursesseeking the advice and assistance of the most senior member of thenursing team, who, as of June 2013, was Debbie McKeown. She was, at

the time of receiving this promotion, precluded from practice in this area.

It appears that the enormity and seriousness of these events did not occurto those in Regional Office until the mid 2013. This coincides withmounting external pressure regarding events in Cape Dorset. Had aninvestigation occurred immediately following the fatality as is requiredpursuant to the Community Health Administration Manual18, it would havedisclosed a serious concern on the part of community members, includingbut not limited to the parents of Baby Makibi, regarding the quality of care

being offered, and in particular, the care provided by Debbie McKeown.However, absent this, Ms. McKeown advanced in responsibility, waspromoted and continued employment in an active fashion until a

Section Administration, Guidelines 05-004-01


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suspension pending investigation in August 2013 regarding a furthercomplaint of harassment.

PART IV ISSUES POSED IN TERMS OF REFERENCE

1. Does the Department of Health have a specif ic process forcompleting an internal review into the administrative processes of acase

It should be noted at the outset that there is a procedure in place for thereporting of and response to a serious or critical incident.19 Interestingly,during my conversation with Regional Director, Roy Inglangasuk, he

advised that there was no formal processes for internal review.

The process is contained in the Community Health Nursing AdministrationManual. A critical incident is defined as:

1. An unplanned Adverse Event that caused serious harm to a client

such as death, disability….;

2. Occurs during the provision of care;

3. Does not result from the client’s underlying health condition;

4. Is not from a risk inherent in providing health services.

These steps include the immediate report (within one hour) by an attendingnurse to his or her immediate supervisor. This in turn is to be promptlyreported to the Director of Health Programs. The steps to be taken by theDirector of Health Programs include:

• Keeping relevant clients, relatives, staff and others informed ofdevelopments;

• Immediately informing the Regional Director;

• In conjunction with the Regional Director, preparing and submitting aBriefing Note;

19 Community Health Administration Manual, Section ADMINISTRATION, Risk Management


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• Leading the preliminary investigation and leading the implementationof any remedial actions as a result of the preliminary investigation;

• Initiating with other appropriate staff and expertise a root causeanalysis of the incident and directing, monitoring actions to be taken;

•

Collating, all relevant records, documents, evidence andcontempor aneous records and ensuring all external forms arecompleted.20

These steps, if followed, provide a comprehensive response to a seriousincident, and, importantly, include the investigation, documentation andanalysis of why the incident occurred, and what steps need to be taken asa result.

However, because the response to a serious incident involves reporting

through only one chain of command, any break or failure within that chainof command can result in a serious incident not being reported orinvestigated. This risk can be corrected by a requirement that reports ofserious or critical incidents are made both through the chain of commandwithin the Department of Health and to an oversight position respecting riskmanagement or quality of care. (See Recommendations 3,4,5,6).

In addition to the reporting of a serious incident, there are policies

governing “continuous monitoring and evaluation of the quality of care

delivered through the Community Health Nursing Program”21 These

include:

• At least an annual community visit by the Director of Health Programsof at least two to four days on site;

• The preparation of community summary reports;

• Administrative review of items such as staff moral (sic),Supervisor orNurse in Charge administrative duties, performance appraisals,rapport of Health Centre within the community.

Many other aspects of the operation of the Health Centre are to be includedin the community visit. As with the policy on serious incident reporting, this

20 Community Health Administration Manual, Guideline 05-004-0121 Community Health Administration Manual, Section: Standards


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policy provides for a reasonable evaluation of the operation of a communityHealth Centre, its relationship with the community and the standards andcompetencies of health centre employees. The efficacy of this importantGuideline is entirely dependent on tasked employees having the time,resources and inclination to undertake the requirements.

2. If so, were they followed in this case

(a) Critical Incident Reporting

The mandated steps respecting investigation of a serious incident were notfollowed in this case. While the matter was reported by attending NurseMcKeown to the Director of Health Services, South Baffin (Heather

Hackney), the “investigation” of the incident appears to have been confined

to a telephone conversation between Ms. Hackney and Ms. McKeownfollowing notice of the fatality. As noted above, a Briefing Note wasprepared by Ms. Hackney April 5, 2012, which appears to be copied to Mr.

Inglangasuk. However, Mr. Inglangasuk states he was only “superficially

advised” of events. The preparation of the Briefing Note tends to indicate

that the matter was considered a serious or critical incident in April 2012.However, apart from this, I could locate no document that indicated that aninvestigation at the community level was undertaken. Nor was there

evidence of fulfilment of the other requirements in the policy relative tocritical incident reporting and investigation.

Apart from the telephone conversation mentioned above, there was nopreliminary investigation to explore the facts of the fatality, compromisingcircumstances, root cause analysis or remedial action. Communicationwith the family was at best marginal, and was primarily comprised of somecommunication by the then nursing staff and a telephone conferencebetween the Chief Coroner and family members during which the family

was advised that the cause of death was SIDS. It should be noted that theparents of Baby Makibi spent many months thereafter with the impressionthat they were in some respect responsible for the death of their son evenafter the revision of the cause of death by the Chief Coroner in July 2012.The grief and guilt associated with this was enormous for them. Incredibly,the Chief Coroner did not directly communicate with them when shereceived a report that concluded that the death was due to pulmonary


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infection. Instead, this information was passed on to a physician who wasscheduled to visit Cape Dorset. It is obvious that this information was

either not communicated at that time or it “fell between the cracks” resulting

in the parents continuing to believe the SIDS conclusion. Interestingly, the

final opinion of June 2015 reverting to the SIDS conclusion was transmittedby the Chief Coroner to the parents in a formal and expeditious fashion, aswas the October 2015 Final Report.

There was no detailed follow up to the fatality and no exploration of thecircumstances despite known difficulties with the functioning of the CapeDorset Health Centre. There was no collection of critical documents,witness statements or charts.

A chart review was requested of Barbara Harvey in September 2012. Thisappears to be inspired by a complaint made to RNANTNU. Ms. Hackneystates in an email to Mr. Inglangasuk:

“I would like an independent review of the chart on the infant death

that occurred in Cape Dorset last spring. One of the staff took theback door approach to reporting concerns around the management ofthis infant to RNANTNU and did not involved (sic) management. Weas a department need to do our due diligence through a careful

review of the files. ….”22

This chart review was completed December 5, 2012. The reviewconcludes that the telephone advice provided by Ms. McKeown wasappropriate as the child was not reported to be acutely ill.

The Regional Director, Roy Inglangasuk, stated that he was not advisedthrough critical incident reporting by the Director of Health, South BaffinRegion, of the incident or the seriousness of it. He states that between the

time of Baby Makibi’s death (April 2012) and the date of restrictions beingplaced on Ms. McKeown’s licence by RNANTNU (June 2012) he was not

aware of the seriousness of the situation nor even that a fatality had

22 Email dated September 21, 2012 from Heather Hackney to Roy Inglangasuk.


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occurred. This is contrary to the Briefing Note indicating that he appears tohave been copied with which contains the information concerning thefatality.

The Director of Health, South Baffin, communicated directly withRNANTNU that adjustments had been made to the practice of Ms.McKeown (not to see children).23 While Ms. Hackney advised that this was

communicated to Regional Office, there are no “c.c’s” appearing on this

correspondence. It appears that if these facts were communicated toRegional Office, it was done in a more informal fashion.

Mr. Inglangasuk further advised that upon learning of the licenserestrictions regarding Ms. McKeown, his responsibility was to ensure thatthe conditions on the license were met. Documents indicate that no recordof the license restriction was on file at Regional Office and no particularswere requested by it. It is quite impossible to monitor conditions if thedetails of those conditions are unknown.

It should be noted that it is the responsibility of the employee (ie Ms.McKeown) to advise his or her employer of the results of any disciplinaryproceedings undertaken by RNANTNU. This is due to protection of privacyconsiderations. Ms. McKeown made the required report to her supervisor.

Regional Office, including Mr. Inglangasuk and the then Deputy Minister,Peter Ma, were aware of the initiation of an investigation involving DebbieMcKeown in February 2012. A formal demand for documents was issuedby RNANTNU in correspondence dated February 27, 2012. Although thiscomplaint to RNANTNU by Ms. Slade was focussed on harassingbehaviour it also raised serious clinical concerns. The documentproduction requested included clinical issues. The request for informationfrom RNANTNU was detailed and included requests for the provision ofcertain patient files among other documentary information. The response

from Mr. Inglangasuk at this time to the request for document productionwas that it imposed an undue burden on staff and the requirement forovertime hours. RNANTNU was invited to attend and conduct its

23 Correspondence from Heather Hackney to RNANTNU dated June 8, 2012. There are no cc’s on this

correspondence.


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investigation. Documents were ultimately supplied to RNANTNU, albeitafter the deadline stipulated in the demand.

To further complicate matters during the time frame January 2012 to June2012, a number of complaints and grievances centred on harassment byMs. McKeown were submitted by Gwen Slade to the Government ofNunavut. The initial complaint to the GN by Ms. Slade was again withrespect to harassing behaviour and not specifically with respect to clinicalcompetencies. The first of a number of complaints was madeapproximately January 28, 2012.

In summary, in the early part of 2012, there was a flurry of complaints,grievances and investigations by RNANTNU. A brief and albeit incompletesynopsis of these steps is as follows:

• Early January 2012 Ms. Slade returns to the Cape Dorset HealthCentre as an agency nurse;

• January 28, 2012 a complaint regarding harassment is submitted byMs. Slade to the Department of Health (S. Burke, Human Resourcesand to the union representative);

• February 20, 2012 Ms. Slade is suspended pending investigation,and moves shortly thereafter from the community;

• February 27, 2012 the Department of Health receives demand

correspondence from RNANTNU regarding an investigation into theconduct of Debbie McKeown;

• March 2012 Heather Hackney submits a complaint regarding GwenSlade to RNANTNU (subsequently dismissed by RNANTNU);

• April 5, 2012 death of Baby Makibi and the Briefing Note is preparedby Heather Hackney;

• April 19,2012 Deputy Minister Peter Ma advises Debbie McKeownthat a prima facie case for harassment has been established and afull investigation will be undertaken. Documents concerning thisinvestigation are either nonexistent or could not be located;

• June 12, 2012 RNANTNU places restrictions on license of DebbieMcKeown not to provide medical care to children under the age of 10;

• September 2012 a written reprimand from Deputy Minister Ma issigned regarding Debbie McKeown. It appears that this reprimandwas never actually delivered to her;


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• September 2012 Mr. Inglangasuk has copies of correspondencebetween Gwen Slade and Barb Harvey, which outline ongoingconcerns;

• September 2012 Ms. Hackney and Mr. Inglangasuk agree that an

independent chart review should be undertaken regarding BabyMakibi by Barbara Harvey;

• May 2013 Mr. Inglangasuk inquires of RNANTNU as to status of

removal of the conditions on Ms. McKeown’s license;

• June 2013 Debbie McKeown is promoted to Supervisor Health Care(nurse in charge) while license conditions remain outstanding. Theserestrictions were also in place while Ms. McKeown was acting in theposition of Nurse in Charge;

• August 2013 further complaints are received regarding harassing

conduct by Debbie McKeown and these complaints together with theperformance of Debbie McKeown are investigated by RegionalOffice. Ms. McKeown is suspended pending investigation;

• November 13,2013 Ms. McKeown receives a letter of reprimand andis required to take an online course regarding respect in theworkplace;

• November 2013 Ms. McKeown returns to work in Cape Dorset.24

It is very likely that the number of complaints, grievances, demands fordocuments, ongoing clinical management issues contributed to confusionand a lack of focus as to what was occurring in the Cape Dorset HealthCentre. However, it would be impossible not to notice that there wereserious issues at the Health Centre in advance of the death of Baby Makibiand following it.

Despite this, no steps were taken at this time to ascertain the nature andseriousness of the allegations made. There was no visit made to theHealth Centre by the Director of Health Services, South Baffin, nor by anyother responsible government employee, to investigate these concerns or

to investigate the circumstances surrounding the death of Baby Makibi.The “full investigation” regarding the complaint of harassment concerning

Debbie MacKeown referred to in Mr. Ma’s correspondence of April 2012 , if

24 See Timeline of Events, Appendix 3


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undertaken, was not accompanied by a site visit or witness statements.Grievances submitted by Ms. Slade to the GN in 2012 were not resolveduntil October 2015.

The more difficult question is not whether the established policies andprotocols were followed but why were they not followed. Was the incidentnot considered sufficiently serious to engage these established steps?Were the steps unknown to the Nurse in Charge, or the Director of HealthServices? Did overwhelming work loads lead to the omission of adequatereporting and response? Did Regional Management not take notice of theoccurrence of an infant fatality in the Community of Cape Dorset?

At the outset it should be stated that the workloads of those practicingnursing in Community Health Centres such as Cape Dorset are

overwhelming. Despite the continuous and significant increase inpopulation, there has been no corresponding increase in staffing levelsover a number of years. Respite, job sharing, collegial meetings andsupport are all a necessary part of maintaining a full complement of qualitycare givers. These important aspects are either absent, or difficult toimplement. As a result, there is large staff turnover. It is also difficult forcommunity members to have confidence in their health care providerswhen there is constant change and a lack of continuity of care.(See Recommendations 9, 11, 18, 19, 26, 27, 28, 32, 33, 34)

As well, the complexity and work load associated with administering healthcentres in remote communities exceeds the capacity of Regional Office.This is due in part to the very nature of the work, and it is exacerbated byhigh turnover and vacancies in key management positions. In many casesI was advised by managers that it is not possible to undertake all duties atall times, and some aspects must be sacrificed to current more urgentsituations.

Reporting requirements and lines of authority are difficult, inconsistent and

lack efficiency. Not all employees of a Health Centre report through thesame chain of command within the Department of Health. Accordingly,those being charged with the overall administration and effectiveness of aHealth Centre lack a full and comprehensive picture. Most notably, whilethe Department of Health may recruit health care professionals, it lacks thebureaucratic authority to terminate employment. The authority respecting


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termination of nursing staff rests with the Department of Finance, EmployeeRelations. (See Recommendations 1, 17)

With respect to discipline, suspension and termination of nurses,efficiencies in many government departments dictate that these functionsexist within a section of expertise (in this case Department of Finance,Employee Relations). This works well with matters that require aconsistent, often ongoing plan of progressive steps. However, it is ill suitedto situations where the health and well being of community members maybe placed at risk if a critical situation is not handled immediately and withauthority. The Department of Health must have the authority to respondimmediately, albeit with advice from Employee Relations and legal experts.Further, clinical issues are not within the expertise of Employee Relationsofficials and the seriousness or magnitude of issues may not be

appreciated by those not trained or working in the health field. (SeeRecommendations 1, 17).

Aspects of recruitment and retention contribute to both turn over and aprobability of hiring nursing staff ill suited to the very high demands ofcommunity health centres. There needs to be a better match between theskills needed by a community health centre and skills solicited in nursingstaff. For example, while emergency care experience is no doubt valuablein a community health centre, the vast majority of work relates to obstetricaland pediatric care. (see Recommendation 9, 32, 33, 35).

In the recruitment process, an in depth review of past nursing history and in

particular, past disciplinary history with Registered Nurses’ Associations

does not occur. While the RNANTNU cannot, for privacy reasons, releasethis on demand in the hiring process, it can do so if the applicant nurse hasconsented to the release of this information. A standard form consent for

release of information should form part of the documents required in anapplication process. (see Recommendation 21)

Furthermore, the present situation regarding discipline of nurses byRNANTNU for current employees requires and is restricted to theemployee nurse reporting to his or her employer the results of any suchinvestigation. There is no direct communication of this between RNANTNU


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and regional managers, due to privacy requirements. Again, this can beaddressed by the consent and direction of the nurse employee. It must bea requirement of all nursing staff to provide such a direction and consent tofacilitate communication on this important issue. Absent consent anddirection, there is no guarantee that a disciplinary finding would even bereported to the employer by the nurse involved. (see Recommendation 22).

To return to the question of why the critical incident of Baby Makibi’s death

was not duly reported in the established protocol, the following are possibleanswers:

• The attending nurse McKeown and the Director of Health Services,

South Baffin simply failed to report the death in the required writtenmanner with the appropriate follow up investigations;

• The Regional Director failed to initiate and oversee the investigativesteps mandated following a critical incident;

• The combination of work load and ongoing conflict at the HealthCentre which had accumulated from January to April, 2012 divertedfocus and attention to the degree that normal steps were not followedby the Director of Health Services, South Baffin and the RegionalDirector;

• The fatality was not considered to be a critical incident within the

Guidelines set out in the Administration Manual;• The Regional Director, Roy Inglangasuk, or the Director of Health

Services, South Baffin, or both, were not fully apprised by NurseMcKeown or the Nurse in Charge in a timely fashion of the preceding

telephone call to the Health Centre by Baby Makibi’s mother, and the

failure to undertake an in person assessment of the infant.

While these possibilities may explain why a critical incident report andfollow up investigations were not immediately made, they do not addressthe fact that no such steps were taken in the months following the fatalitywhen facts became clearer regarding at least the failure to do an in personassessment of the infant. I could find no evidence as to why aninvestigation regarding the fatality did not occur, at least at the time thatlicense restrictions were imposed on Ms. McKeown by RNANTNU, if notprior to that point.


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(b) Monitoring and Evaluation

There were no documents provided to me that evidenced that ongoingmonitoring and evaluation occurred with respect to the Cape Dorset HealthCentre. It may be that some assessment occurred when combined with acommunity visit that had other agenda items. It is clear that detailedperformance plans and appraisals regarding key positions on the CapeDorset nursing staff did not occur. Indeed, this is one of the reasons thatresulted in extremely conservative advice from Employee Relations as tothe suspension or termination of Ms. McKeown. The first serious effort atreviewing the conduct of Ms. McKeown occurred as a result of the further

2013 harassment complaint. Absent detailed and consistentdocumentation of performance evaluations, corrective actions, complaints,investigations and reprimands, options for correction of or termination ofemployment become extremely difficult. None of these issues was properlydocumented in the case of Ms. McKeown either by the Nurse in Charge atthe Health Centre, or bureaucrats up the line of authority.

In speaking with residents of Cape Dorset, there appeared to be no efforton the part of the Department of Health to monitor, assess or address therapport of the Health Centre within the community. This undoubtedlycontributes to feelings of alienation on the part of community members.


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3. WHAT WERE THE FINDINGS OF THE INTERNAL REVIEWCOMPLETED BY THE DEPARTMENT OF HEALTH

As indicated above, it appears that the seriousness of the circumstancessurrounding the death of Baby Makibi did not come to the attention of

Department of Health Regional Office until at least1 ½ years after the

event. It is difficult to understand in the circumstances why such an eventcould go unnoticed given the flurry of difficulties which had arisen at theCape Dorset Health Centre in 2012 and 2013. Even if the fatality itself wasnot properly reported, there was awareness of difficulties at the HealthCentre as a result of grievances being filed, investigations by RNANTNUand the imposition of restrictions on the license of Ms. McKeown. It is notsufficient for Regional Directors or other responsible bureaucrats to simplyrespond in the moment to grievance procedures and demands fordocuments from RNANTNU. Those persons with ultimate authority

regarding the functioning of community health centres must ask “what is

going on and why”. This never happened in the case of Baby Makibi.

Action was taken in the summer of 2013 but it was not with respect to theTimilak matter. A further complaint of harassment had been receivedregarding the conduct of Debbie McKeown and interviews, community

visits and documentary reviews were focussed on this. While none ofthese actions touched upon the death of Baby Makibi, it should be notedthat a concentrated effort was made at this time by Health Regional Officeto manage or, terminate the employment of Debbie McKeown. Advice fromDepartment of Finance, Employee Relations precluded this from occurring.

As indicated above, the absence of detailed and consistent documentationresulted in the disciplinary options being severely limited.

In an interview conducted with Mr. Inglangasuk in Pangnirtung April 29,

2015, he advised that there was no internal review regarding the death ofBaby Makibi. He further advised that when Heather Hackney left theposition of Director of Health Services, South Baffin in March 2013 he

started to appreciate the seriousness of Ms. McKeon’s conduct. This

contradicts his position in his email of May 2013 to RNANTNU in which heinquires as to the status of the license restrictions and his wish to interview


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Ms. McKeown regarding the position of Nurse in Charge of the HealthCentre as well as his unequivocal endorsement of Ms. McKeown. In fact,there was no focus at this time regarding the fatality. Rather, the focus,more than one year later, was with respect to the further harassmentcomplaint made by health workers at the Cape Dorset Health Centre in thesummer of 2013.

There are no documents provided to me which indicate that there was anyinvestigation at this time touching upon or specific to the death of BabyMakibi apart from the chart review undertaken by Ms. Harvey in September2012. All interviews conducted by me indicate that at no point was aninternal review undertaken by the Department of Health or Regional Officespecifically regarding the Timilak fatality. In addition there was no factfinding process undertaken by the Director of Health Services, South Baffin

regarding the fatality, nor following the imposition of the conditions on Ms.McKeown’s license regarding pediatric care. There were no fact finding

meetings regarding the performance, skills and management of DebbieMcKeown or the Nurse in Charge relative to the Timilak matter.

The initial concerns respecting Cape Dorset submitted by Gwen Slade inJanuary 2012 focussed on harassment in the work place. However, notlong thereafter, clinical concerns were raised by Ms. Slade to RNANTNU.

It was the investigation by RNANTNU and these complaints which linkedthe concern around the care or lack thereof respecting Baby Makibi. It wasthis investigation by RNANTNU that resulted in restrictions being placed on

Ms. McKeown’s license precluding her from providing nursing care to

children under the age of 10, in June 2012. The then Director of HealthServices, South Baffin, Heather Hackney, was aware of the death of BabyMakibi at the time its occurrence, and was aware in June 2012 of the

restriction placed on Ms. McKeown’s license. She was also aware of the

grievances submitted by Gwen Slade regarding harassment and conducton the part of Ms. McKeown. Despite this, no steps were taken by her toinvestigate these events in 2012 or indeed at any time thereafter.Incredibly, the license restriction appears not to have been formallyreported in writing or in detail by her to Regional Office. Her advice toRegional Office regarding the complaints/grievances which had beensubmitted by Gwen Slade in early 2012 focussed on how they could be


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refuted, rather than assessing whether there was legitimacy to theconcerns.

It is possible that Ms. Hackney made a judgment call regarding thecredibility of the complaints made by Ms. Slade. There had been priorissues in 2007 in which the suitability of Ms. Slade for northern remotepractice surfaced. However, the responsibility of this position required adispassionate and objective review of the early 2012 complaints, which wasnever in fact undertaken.

Commencing in the summer of 2013, when further complaints ofharassment concerning the conduct of Debbie McKeown were received,steps were taken to seriously evaluate her performance. Visits to thecommunity were made, evaluations were undertaken, chart reviews were

requested. However, none of these steps were taken as a result of anyfocus respecting the Timilak matter. During the course of theseinvestigations, Ms. McKeown was suspended from work at the CapeDorset Health Centre.

In November 2013 significant deficiencies regarding the administration andoperation of the Cape Dorset Health Centre were communicated in writingby the Regional Director, Roy Inglangasuk, to Debbie McKeown.25 Someof the concerns included:

• The advice by health centre staff that a toxic work environmentexisted arising from the management style of Ms. McKeown;

• Poor communication with staff;

• Haphazard approaches to normal health centre programs, such asTB programs, treatment programs, emergency services, schoolhealth programs and so on;

• Lack of “connectedness” with the community;

• Possible poor patient charting;

• Refusal of nursing staff to return to Cape Dorset as long as Ms.McKeown remained manager.

25 Correspondence dated November 13, 2013.


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Ms. McKeown was advised that “the management of the Cape Dorset

health centre is not meeting the standards of our other health centres on

Baffin Island”. Mr. Inglangasuk further advised:

“I deem the following factors to have contributed to the weak

operations to one our (sic) larger health centres; lack of

communication, micromanagement of our CHN’s, unclear

expectations resulting in poor healthcare programming inCape Dorset and not meeting the needs of the community,intimidation resulting in excellent nurse clinicians refusing to

work at the Cape Dorset health centres and overall poorleadership skills resulting in conflicts in the workplace.”

While this correspondence clearly identifies significant concernswhich had been identified as a result of the investigationundertaken by Regional Office, it sadly does not mention thedeath of Baby Makibi.

In December 2013 a lengthy history of concerns was communicated in

writing by Gwen Slade to MLA David Joanasie. The initial position of theGovernment of Nunavut appears to have been one emphasizing damagecontrol and characterizing the matter as employee conflict.

Regional Office started to connect the dots in January 2014.

On January 13, 2014 Elise VanSchaik expressed serious concernsregarding the events which had transpired in Cape Dorset:

•

She states that the letter of June 8, 2012 authored by HeatherHackney to RNANTNU advising that Debbie McKeown would

continue to provide nursing care with “suitable adjustments” to her

tasks was not copied to anyone in the Department of Health andevidenced that this decision was made without any consultation withother Department authorities;


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• The opinion of Ms. VanSchaik that this step was both negligent and

incompetent in that Ms. Hackney, in the view of Ms. VanSchaik “not

only had a responsibility to strictly enforce a work-place setting to

closely monitor this employee, but failed in her responsibility toensure that a thorough investigation of the facts were undertaken and

that the safety of the public was given top priority.”;

• There was no information on the file that indicated that Ms. Hackneyhad done any supervision of this employee nor which would indicatethat any investigation was done regarding the bases of the restrictionregarding pediatric care;

• Ms. VanSchaik advised that in her conversations with RNANTNU itwas revealed that this governing body had been inundated withcomplaints about other, some former, employees over the pastseveral years and the Department had no evidence of this. Itappeared that fact finding meetings by the Director of Health Serviceshad not been conducted regarding many of the complaints made toRNANTNU;26

• Ms. VanSchaik was of the view that a full and coordinated

investigation needed to take place and that issues raised in thecorrespondence from Gwen Slade to MLA Joanasie needed to beaddressed;

• She was also of the view that despite the return of Ms. McKeown toher duties in Cape Dorset in the fall of 2013 against the opinion ofRegional Office staff, she should now be terminated fromemployment and investigations should continue regarding the priorperformance of Ms. Hackney as Director of Health Services, SouthBaffin.

This email demonstrates just how much the Department, and specificallythe Regional Office did NOT take steps regarding the Timilak event in Cape

26 It should be noted that RNANTNU would not communicate the fact of or outcome of a complaint to the

Department of Health unless the Department was itself the party complaining due to privacy issues.


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Dorset as late as January 2014. It also speaks to the lack of properdocumentation.

It appears from my review that these concerns, coming late as they did inthe history of events, arose as a result of external pressure andinformation, including the ongoing communication by Gwen Slade, and theinquiries initiated by David Joanasie, MLA for Cape Dorset. The efforts andquestions arising in Regional Office at this time did not arise as a result ofits own internal processes or adherence to established guidelines andprotocols.

Matters from this point forward did not focus on the conduct of a full andsubstantial review of circumstances that had transpired in Cape Dorset.Instead, protracted discussions and disagreements occurred both within

Regional Office and between Regional Office and Employee Relations (thelatter with respect to what steps could or should be taken regarding theongoing employment of Ms. McKeown). Mr. Inglangasuk advised that hewas directed by Employee Relations to cease any further investigatorysteps regarding Ms. McKeown. Employee Relations states that, whileconcerns were raised regarding further steps, there was no such direction.

As a result, focus was lost on those matters which actually gave rise to this,including the death of Baby Makibi. It became easy for the focus to beNurse McKeown rather than the internal failings of the Department.

As indicated above, there was no internal review specific to the Timilakcase, nor was there an internal review in which the Timilak case was evena peripheral consideration. There was a file review regarding the fatalityrequested of Barb Harvey regarding the fatality, but this in no senseconstituted an internal review. At the latest, once a detailed investigationwas undertaken between August 2013 and November 2013, it is hard tounderstand how the connection could not have been made between thepoor practice and management at the Cape Dorset Health Centre and theinfant death. This is particularly the case, as in July 2012 the cause of

death was amended by the Chief Coroner from SIDS to widespreadpulmonary infection. This amendment appears not to have beencommunicated by the Coroner to Regional Office, or, if it wascommunicated, it went unnoticed.


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4. WERE ALL GOVERNMENT OF NUNAVUT POLICIES,PROCEDURES, TRAINING AND GUIDELINES RESPECTING NURSINGCARE, STANDARDS OF NURSING CARE AND COMPLAINTSPROCESSES FOLLOWED IN THE TIMILAK CASE

(a) Nursing Care and Standards of Nursing Care

Not all applicable guidelines and policies were followed with respect to theTimilak case respecting nursing care and standards of nursing care.

The orientation for Ms. McKeown did not occur until the fall of 2013, longafter her initial hire date of August 2011. There are additional questionsconcerning the adequacy and cultural components of the orientation

program.27 (See Recommendation 32, 34, 35).

Although Ms. McKeown indicated at one point that she was not aware ofthe policies regarding assessment of infants under the age of one (1) year,these policies are clearly stated in the Community Health AdministrationManual. This document is a fixture in all Health Centres.

As indicated above, there are a number of areas of failure to adhere to ormeet then existing policies and protocols:

• Baby Makibi was not seen in person at the time of the initial phonecontact with the Health Centre, which is contrary to the policiesregarding assessment of infants and telephone triage. Approximatelysix months after the fatality, there appeared to be the conclusion thatthis policy did not apply respecting Baby Makibi as it falls under the

policy heading “ Accutely Ill Infants”. However it should be noted that

Policy 2 under this heading states “ All infants less than one (1) year

of age must be weighed naked at each visit including public health

clinics. All weights shall be documented on the gender/age

appropriate growth chart”. Although under the same policy heading,

27 Nunavut Nurse Recruitment and Retention Survey, RNANTNU, 2005 indicates that “A large number of the

respondents were concerned that the length of the orientation process was insufficient, that orientation was not

always provided in a timely manner, or was not provided for all nurses.” At page 18.


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this clearly does not relate only to acutely ill infants. In addition, thisconclusion ignores the policy on Telephone Triage regarding the inperson assessment of children under the age of 1 year.

•

The death of Baby Makibi was not reported/investigated as a seriousincident in the manner mandated by the Administration Manual;

• Accordingly, there was no coordinated effort to communicate with andupdate family members, no preliminary investigation, no remedialactions identified, no initiation of a root cause analysis, noorganization of a disclosure team and no in person follow up meetingwith members of the family by any person in the Department ofHealth;

• No investigation occurred immediately following the death of BabyMakibi as to remedial steps required, collection of witnessstatements, charts and other critical documents. There was nosignificant communication with family members;

• During the critical time in question there was no substantive ongoingmonitoring and evaluation of the Cape Dorset Health Centre.Performance appraisals remained undone or incomplete and were

not filed with or maintained by Regional Office, community summaryreports appear not to have been prepared, and evaluation of rapportbetween the Health Centre and the community did not occur;

• There appears to have been no monitoring or documentation onmonitoring regarding the license restriction of Ms. McKeown andwhether in fact it was being honoured, and no fact finding regardingthe original basis for the restriction.

(b) Complaints

The capacity to make a complaint and the processes available to make acomplaint regarding the quality of a nurse’s care, or the ethical practice of anurse are not well known or understood by members of the public. At


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present, there are two “formal” avenues through which a complaint can bemade.

(a) A complaint can be made by any person to RNANTNU regarding theconduct of a nurse.28 The complaint must be in writing and must bedirected to RNANTNU which is obliged to review and investigate allcomplaints received.

In addition to this, all nurses (who must be registered withRNANTNU) are obliged to report alleged incompetence or unethicalpractice of another nurse. Failure to make such a report is itselfunprofessional conduct.29 This means that if a nurse is aware ofpossible unprofessional conduct on the part of another nurse, thefailure to report this can result in discipline for the nurse not reporting

it.

(b) A concern or complaint can be made by a member of the public tothe Office of Patient Relations, Government of Nunavut.

With respect to members of the public, many are not aware of either ofthese avenues. More often, concerns are made known to the MLA for thecommunity, which he or she may then raise either in a public fashion orwhen the Legislature is sitting, or by communicating it to the MinisterResponsible for Health. This way of making a complaint has no process,defined procedure or outcome and accordingly, lacks both immediacy andeffectiveness. Ironically, despite this, it is likely these type of steps thatwere central to the commissioning of this Review.

(i) Complaints to RNANTNU

With respect to complaints made to RNANTNU, while this avenue is the

most appropriate regarding serious concerns with respect to the quality ofhealth care and standards of nursing care, it is virtually unknown tomembers of the public. In addition, the understandable requirement that

28 Nursing Profession Act, SNWT 2003 c. 15, s. 3429 RNANTNU By-Laws Section 5


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complaints be made in writing is a barrier to those whose literacy in Englishis limited. Complaints made to RNANTNU were investigated resulting infirstly the conditions on the license of D. McKeown, and ultimately thesuspension of that license. However, these complaints were not made bymembers of the public, but rather by nurse(s).

(ii) Complaints to the Office of Patient Relations

With respect to issues that are brought forward to the Office of PatientRelations which was established in July 2013, it was reported to me that nocomplaints had been received on issues such as misdiagnosis ornegligence. The majority of complaints are with respect to access issues,issues of resource allocation, such as home care, medical travel andcapacity to escort.

When complaints are received by this Office, the first inquiry is whether thecomplainant has raised the issue with the nurse in charge so that correctioncan occur at the point of care. If that has been unsuccessful, the Office ofPatient Relations will look into the issue and, in doing so, may contact theresponsible Regional Director. At this point, the matter is out of the handsof the Office of Patient Relations, and decisions are made at the regionallevel as to whether investigative steps such as a chart review should occur.

At times, mediative steps are taken to facilitate communication between thecomplainant and those within the health care system responsible for thedecision or process which is causing the concern. This can at timesinvolve the Territorial Chief of Staff, or other appropriate health care teams.The Office of Patient Relations can make recommendations in particularmatters and can suggest improvements to policy or processes. However,this Office has no ultimate authority to direct specific actions. No complaintwas specifically directed to the Office of Patient Relations regarding theTimilak matter.

In addition this Office has limited resources to conduct outreach andawareness campaigns and has no present capacity to have communitypersonnel in places such as Cape Dorset. I was advised that there arethree positions associated with this office, one of which has remainedunfilled.


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This Office has the potential to be extremely valuable if appropriatelyresourced, in assisting in solving process and administrative issues,facilitating communication and providing an avenue for the respectfulinteraction with patients and users of the health care system. It is notsuited, by structure and authority, to solving serious patient care/ nursingstandards concerns.

(iii) Complaints – General

In a more informal way, problems which arise regarding the competency

and standards of nursing care can be addressed through an “as needed”

process within Regional Office. This allows for a more immediate andresponsive reaction when a problem has been identified. It can include a

review of the employee’s work, interaction with colleagues, chart audits,

investigative steps through fact finding meetings and what are known as360 Reviews. The 360 Review contemplates the involvement of multiplesources of information to assess the performance of an employee. Thedifficulty with this avenue is that it depends for initiation on a regional officeemployee. There are no defined triggers for engaging this process and nopolicies as to when and what type of investigation should occur. (SeeRecommendation 8).

In this matter, complaints were also made directly to the Government ofNunavut. Notably, complaints were made commencing in January 2012 byGwen Slade to Human Resources and to union representatives. Inspeaking with Shawn Burke, Manager, Human Resources, he advised thatcomplaints which were sent to him, authored by Gwen Slade, were sent onto Heather Hackney, as the Director responsible for the Cape DorsetHealth Centre, and Roy Inglangasuk, the Regional Director. Mr. Burkefurther advised that no response was received from either party. He furtheradvised that Regional Office is better positioned to evaluate clinical

concerns. Finally, he advised that Employee Relations was involved in thematter at an early date, and he (Mr. Burke) had no further involvement inthe matter after January 2012.


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Mr. Burke’s evidence conflicts with advice received from Mr. Inglagasuk

that he was not aware in January 2012 of the concerns being raisedregarding the Cape Dorset Health Centre.

While the avenue exists to submit a complaint directly to the Department,efforts in this regard on the part of Ms. Slade resulted in no immediate

action being taken or even pursued, apart from Ms. Slade’s suspension

pending investigation. The complaint process eventually evolved into agrievance procedure which